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HomeMy WebLinkAbout945743 Fonn 3000-3 (May 2006) UNITED STATES DEP ARTMENT OF THE INTERIOR BUREAU OF LAND MANAGEMENT ASSIGNMENT OF RECORD TITLE INTEREST IN A LEASE FOR OIL AND GAS OR GEOTHERMAL RESOURCES FORM APPROVED OMB NO. 1004-0034 Expires: April 30, 2009 Lease Serial No. WYW63819 Lease Effectivo Date (Anniversary Date) 07/0111978 New Serial No. Míneral Leasíng Act of 1920 (30 U.S.C. 181 et seq.) Act for Acquired Lands of 1947 (30 U.S.C 351 - 359) Geothermal Steam Act of 1970 (30 U.S.C. 1001-1025) Department of the Interior Appropriations Act, Fiscal Year ;1981 (42 U.S.C. 6508) Type or print plainly In Ink and sign In Ink. PART A: ASSIGNMENT 1. Assignæ* FrIUlk A. Ford, Trustee for Ford GroupIi'õur, SIred: P.O. Do]; 457 City, State, Zip Code DeLand, FL 327Z1oØ457 i 10. Assignor Petro Atlas Corpora fon i P.O. Do]; 281089, Lakewood, CO 80228 ·If more 1ban roe œsígnee, àJeckbeœ 0 8Dd 1íst1be name(s) and øddœss( es) ofll1l addIional assignees on page 2 ofthís fonn oc on a separaie attacl1ed, sbt:et Œ paper. 1bis m:mI1itIe 811SÍg111DmtÍ5 for: (Chedc one) ø Oil and Gas Lease, oc 0 GeoIhemJa1l.ease InttmItcœvcyed: (Ched; eneor both, as a¡proprlate) 0 Ræoo1 TItJe, III Oveniding RoyaIW, payment out of¡roductíon ocotbecsímilar interests orpaymenls 000067 2 This IISIIÍgJIDXIIt oooveys 1110 foDowing interest: Land Description Peroent of Interest Percent of Additional space on page 2, if needed. Do not submit documents or agreements Ü\med Cœveyed Retained Overridín£ Royalty olher than this form; such documents or agreements shall only be referenced herein. Simílar terests ~X Previously onveye< reserved or conveyed a b c d e f Township 25 North, Ralnge 111 Wat, 6th P.M. 0.69376% SectIon 17: Lots 1-8 SeetIon 18: 1.0..5-12 Llnnln County, Wyoming ContalnlDg 636.45 aues, more or las. RECEIVED 3/9/2009 at 10:58 AM RECEIVING # 945743 BOOK: 717 PAGE: 67 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY FOR BLM USE ONLY - DO NOT WRITE BELOW THIS LINE UNITED STATES OF AMERICA This usignment Is approved IOlely for administrative purposes. Approval doe. not warrant that either party to thl. mlgnment hold. legal or equitable title to thi. lease. D Aøsigmnent approved for above described lands; D Assignment approved for attached land description Assigmnent approved effective D Assignment approved for land description indicated on reverse of tIús fonn By Bureau ofLand Management (BLM) (Continued on page 2) (Title) (Date) Part A (Continued): ADDITIONAL SPACE for names and addresses of additional assignccs in Item No.1, if needed, or for Land Desoription in Item No.2, if needed. STATE OF COWRADO ) ) ss. COUNTY OF JEFFERSON) OD this £ day of ::rCf.4JfA.M ï ,2009, persoDally appeared before me James L. HardeD Ill, al PrelldeDt of Petro Atl.. CorporatloD, the Ilper of the above IDltrumeDt, who duly ackDowledged to me that he executed the lame. WITNESS my haDd aDd official seal. My commlllloD explreø: 7 ~ ~ - dO I ~ di(n do- ~ ~ Ufjn Notary Public ÜOv068 UNDA.KAY PRUYN NOTARY PUBUC STATE OF COLORADO MY COMMISSION EXPIRES 07/22/2012 PART B· CERTIFICATION AND REQUEST FOR APPROVAL 1. The Assignor oertifies 88 owner if an interest in the above d08ignated le88e thst he/she hereby 88signs to the above assignec(s) the right8 øpcoified above. 2. Auignee oertifies as follows: (a) Assignee is a oitizen of the United States; øn assooiation of suoh oitizens; a munioipality; or a oorporation organized unclcr the laws of the United States or of øny State or territory thereof. For the aøøignmcnt ofNPR·A Icas08, assigncc ia a oitizen, nationa~ or resident alien of the United Statc8 or aøaooiation of such oitiZCl18, nationals, resident sHena or private, publio or nmnioipal oorporationa, (b) Assignee ia not oonaidered a minor under the laws of the State in whioh the landa oovered by thia 88signment arc looated; (0) Aøøigncc'a ohargeable intereøta, dircot and indirect, in eaoh publio domain and aoquired landa separately in the same State, do not exoeed 246,080 aores in oil and gasle88es (ofwhioh up to 200,000 aores may be in oil ønd gas options), or 300,000 aores in leases in eaoh leasing Distriot in Alaska of whioh up to 200,000 sores may pein options, if this is an oil snd gss lease iøøucd in aooordønoe with the Mineral Leasing Aot of 1920, or Sl,200 aores in øny one State if this is a geothcrmallcase; (d) AU parties holding øn interest in the a88Îgnment are otherwise in oomplianoe with the regulations (43 CFR Group 3100 or 3200) and the authorizing Aots; (e) Assignee is in oomplianoe with reolamation requirements forall Federal oil and gas lease holdings aørequired by ØCIO. 17 (g) of the Mineral Leasing Aot; and (t) Aøøigncc is not in violation of seo. 41 of the Mineral Leasing Aot. 3. Aaaigncc's signature to this a88Îgnment oonøtÎtutcs aooeptanoe of all applioable tenna, oonditiona, stipulationø and r08triotionø pertaining to the lease dcaoribed herein. For geothermal auignmenta, an overriding royalty may not be lO8s than one-fourth (1/4) of one peroent of the value of output, nor greater than SO peroent of the rate of royalty due to the United States when this assignment ia added to all prcviouøly oreated overriding royalties (43 CFR 3241). I oertify that the statements made herein by me arc true, oomplete, and oorrcot to the best of my knowledge and belief and arc made in good faith. Excouted this 29th day of January 20 09 Excoutedthis 25th day of February 20 ~ Name of Auignor as shown on ourrent leaae Petro Adas Corporation or 6~Ah.IJ in ,..141 ~:m:. Sianature) President --~ .~þ¡ Aøøigncc,- æ r&-<-J (Signature) b ~tf' Pð-lvt-- or Attorney-in-faot (Signature) P.O. Dos 281089 Secretary (City) (Assignor's Addras) co (State) 80228 (Zip Code) Lakewood Title 18 U.S.C. Soo.lool makes it a orime for øny person knowingly and willfully to make to øny Department or agenoy of the United States any faløc, flOtitioul, or fraudulent ststcmcnta Œ rcprcacntationa 88 to any matter within its juriadiotion. (Continued on page 3) (Fonn 3000-3, page 2)